A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
Rapid pulse.
Decreased B/P.
Pallor.
Flushed Face.
Correct Answer : A,B,C
Choice A rationale
Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body’s tissues.
Choice B rationale
Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure.
Choice C rationale
Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale.
Choice D rationale
A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Potential Condition.
The infant’s symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant’s neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
Correct Answer is A
Explanation
Choice A rationale
Mucus and blood in stools, often described as “currant jelly” stools, are a common symptom of intussusception.
Choice B rationale
Increased appetite is not typically associated with intussusception. In fact, children with this condition may experience decreased appetite due to abdominal pain.
Choice C rationale
Jaundice is not a symptom of intussusception. Jaundice, a yellowing of the skin and eyes, is more commonly associated with liver conditions.
Choice D rationale
Drooling is not a typical symptom of intussusception. Symptoms of intussusception are primarily gastrointestinal, including abdominal pain and bloody stools.
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